Gestational Trophoblastic Disease: A Case Report
1st Year MBBS, Islamabad Medical and Dental College
Gestational trophoblastic disease (GTD) refers to a range of pregnancy
related disorders which consists of premalignant disorders of complete and partial
hydatidiform mole and malignant disorders of invasive mole, rare placental site
trophoblastic tumor and carcinoma. These malignant forms are known as neoplasia or
gestational trophoblastic tumors. It is unique in gynecologic cancers; Gestational
Trophoblastic Neoplasia does not need a deﬁnitive histopathologic diagnosis. After
eviction of Molar pregnancy, diagnosis can be made with only laboratory tests when there
is persistence increase of human chorionic gonadotropin (hCG) hormone.1
In the case of appropriate management, Low risk gestational trophoblastic neoplasia can
be cured with single agent chemotherapy.260 years ago, most of the women have died from
malignant disease. The overall cure rates can exceed 98 percent with fertility retention
by improving the management and follow up protocols. This success can be described using
human chorionic gonadotropin hormone as a biomarker, by the development of effective
treatments, and centralization of care.3Even though diagnosis is advantageous, patients
with GTD must face loss of pregnancy, repeated hCG measurements with viable need for
chemotherapy, surgical procedure for expulsion and the advice to postpone future
pregnancy. It has been observed that these patients experience different psychological
complaints, which include various psychological domains, such as reproductive concerns,
anxiety, depression and distress.4
A 35-year-old female patient is presented in OPD of OBS/GYNAE department of Akbar Niazi Teaching Hospital (ANTH) on 23rd Oct,2022, with complain of fever and bleeding after miscarriage 15 days back, along with dysuria and urinary urgency.
History of presenting illness
According to the patient, she reported in the private clinic for the ﬁrst time when she had PV bleeding after she missed her periods. Her UPT was done which was found to be positive. Her DNC was done due to suspicion of incomplete miscarriage. According to the patient she had hx of excessive vaginal bleeding during the DNC. No histopathology report available of product of conception, 2 blood transfusions were done during the procedure. Patient remained at home for 10 days with a history of PV bleed and fever off and on. Patient was received in ANTH on 23rd OCT 2022, with complaints of excessive bleeding since morning and fever. Past medical history was not signiﬁcant. No signiﬁcant history of any drug intake and drug allergy. She belongs to middle socioeconomic status.
Patient was received in the ER. Patient was well oriented in time and space. Bp 90/60 mmHg. Pulse 11bpm Respiratory rate 18 bpm. Temp afebrileMarked pallor was noted. Abdomen was soft and nontender.Foul smelling vaginal discharge with bleeding. Old, ruptured hematoma on lateral vaginal wall noted. Cervix could not be visualized properly.
Hospital treatment summary
Patient was admitted and she was treated as a case of septic shock. Triple Regimen antibiotics were started. Blood transfusions were given. On the basis of her history and clinical ﬁndings, a blood sample for BHCG was sent and a departmental scan was planned. On receiving her BHCG was 5316mlU/ml and the departmental scan showed an enlarged uterus with heterogeneous cystic structure in the lower uterine segment with the CET not intact and marked increased vascularity was noted in that region. Patient was prepared for EUA after stabilization. Attendants were counseled regarding all risks. Patient was in a lithotomy position and anaesthetized. Examination was done, patient was bleeding profusely from hematoma drained. Vaginal tears were repaired with Vicryl 1, hemostasis was secured with very difﬁcult. Rectal mucosa was intact, no stitch felt. Patient was examined by surgeons, and a proctoscopy was done. There was no active bleeding, vaginal packing was done with one abdominal sponge.
- Lateral vaginal wall hematoma.
- Lateral vaginal wall tears extending up to the cervix and post vaginal fornix.
- Major vessels and bleeders from tears.
- Profuse bleeding from tears.
- Estimated blood loss 2 to 3Liters.
- Teared area necrosis and foul smelling.
- Healthy cervix.
- 3 units RCCs transfused per op.
- 6 FFPs transfused.
Serial BHCG Reports
Gestational trophoblastic disease is a group of rare diseases in which abnormal trophoblast cells grow inside the uterus after conception (the joining of sperm and egg). GTN subset of malignancies that have varying propensities for local invasion and metastasis. It can be cured by chemotherapy and surgery for tumors that do not respond to chemotherapy. There are different types of GTD which include premalignant disease and malignant disease. Premalignant diseases have two types, Complete Hydatidiform Mole (C M) and Partial Hydatidiform Mole (P M). Malignant Diseases (Gestational Trophoblastic Neoplasia) include invasion mole, placental site trophoblastic tumor (PSTT), epithelioid tumor and gestational carcinoma. Calculated incidence of complete mole occurs 1 in 1945 pregnancies and partial mole includes 1 in 695 pregnancies. Clinical features of hydatidiform mole are irregular vaginal bleeding, positive pregnancy test, uterus is larger than POG, hyperemesis gravidarum, theca leutin cysts, early onset of preeclampsia, presence of grapes like vesicles. If HCG levels are higher than 100000 ml U/L, excessive uterine enlargement, Theca leutin cyst is 6cm or larger, then there is high risk for developing Post molar tumor. Histological evaluation of material accessed from the surgical and medical management of all miscarriages is recommended to eliminate trophoblastic neoplasia if none of fetal parts are recognized at any stage of pregnancy. Women who experienced miscarriage should be highly recommended to do UPT3 weeks after miscarriage. There is no clinical sign for routine use of second uterine evacuation. If the recurrent molar tissue is limited to the uterine cavity, then it may be beneﬁcial for symptom control in selected patients with heavy bleeding curative. For the primary treatment of patients diagnosed with gestational trophoblastic neoplasia (GTN), The International Federation of Gynecology and Obstetrics scoring system is used to guide Worldwide.5
According to FIGO scoring
Low Risk GTN
In FIGO score 6 or less. Drugs schedules: single agent chemotherapy Most commonly used regimen: Methotrexate: 1 mg/kg 1M on days 1, 3, 5, 7 Folinic acid 0.1 mg/kg 1M on days, 2, 4, 6 and 8. Side Effects: Stomatitis, conjunctivitis, abdominal and chest pain. Actinomycin- D: (primary therapy in case of abnormal liver function).
High Risk GTN
Stage I, II, III With FIGO score 7 or greater or Stage IV,Primary intensive combination chemotherapy Regimens given: MAC, Modiﬁed Bagshawe (CHAMOCA), EMA-CO, EMA-EP. For Complete mole, if hCG has reverted to normal within 8 weeks of the pregnancy event then follow up will be for 6 months from the date of uterine removal. If hCG has not reverted to normal within 8 weeks, then follow will be for 6 months from normalization of hCG level. For Partial mo1e follow up till hCG has returned to normal on two samples atleast 4 4 weeks apart. Women who have not received chemotherapy no longer need to have hCG measured after any subsequent event.
Gestational trophoblastic disease is characterized by abnormal proliferation of pregnancy associated trophoblastic tissue with malignant potential. They are potentially curable with retention of reproductive function once the correct diagnosis is made and treatment is commenced early with adequate follow up. As per our understanding this bunch of entities unfolds, that novel biomarkers are required for these rare conditions to assist in diagnosis, management, and prognosis stratiﬁcation.6 Long term results of treated women are generally magniﬁcent with an overall cure rate about 100 percent, further pregnancies are achieved in 80 percent women following with multi agent chemotherapy or methotrexate alone. There is risk of premature menopause for women, who are treated with combination agent chemotherapy. Women who are convergent to the age of 40 and are treated with high doses of chemotherapy then they should be informed about the negative impact on fertility. Chemotherapy and Gestational Trophoblastic Diseases (GTD) hardly ever affect the later pregnancies, but the rate of repeat mole is comparatively high.
Ultrasound of patients
Xray of the Patient
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- Seckl MJ, Sebire NJ, Berkowitz RS. Gestational trophoblastic disease. The Lancet. 2010 Aug 28;376(9742):717-29.
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- Parker VL, Cushen BF, Hills A, Kandiah K, Palmer JE, Singh K, Hancock BW, Tidy JA, Winter MC. Flat- dose versus weight or body surface area-based methotrexate dosing in low- risk gestational trophoblastic neoplasia. Gynecologic Oncology. 2023 Feb 1;169:34-40.
- . Strickland AL, Gwin K. Gestational trophoblastic disease-rare, sometimes dramatic, and what we know so far. InSeminars in Diagnostic Pathology 2022 Mar 22. WB Saunders.
- Kim JH, Park DC, Bae SN, Namkoong SE, Kim SJ. Subsequent reproductive experience after treatment for gestational trophoblastic disease. Gynecologic oncology. 1998 Oct 1;71(1):108-12.
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